New Research Challenges Idea Behind ‘Deaths of Despair’

Low-income Americans are dying at a higher rate than high-income Americans. In fact, the life span of low-income Americans is becoming shorter – a trend largely attributed to drug and alcohol-related deaths, which has been called deaths of despair.

“The least well-off Americans have seen their wages become stagnant, their jobs become obsolete, their neighborhoods crumbling in various ways. And so there’s a thought that that leads to despair for less-educated Americans and they turn to drugs or suicide,” explained University of Michigan professor Arline Geronimus.

Geronimus was the lead on a new study that argues higher rates of death among low-income Americans are due to inequity, not despair. She talked about her research in a conversation with West Virginia Public Broadcasting’s health reporter Kara Lofton.

Geronimus: That’s correct. My theory doesn’t necessarily challenge that the increase is due in some way to the fact that life has gotten much harder. I mean, resources have gotten fewer, for the working class and for the least-educated Americans. But it challenges whether their response to it is despair, as opposed to working that much harder to make ends meet, to support their families, to overcome the obstacles in their way.

There’s a rich literature suggesting that when you work so tenaciously against barriers or difficulties or trying to make ends meet or working multiple jobs, that [in] itself can lead to chronic physiological stress reactions in your body that over time cause wear and tear in your body and can lead to sort of accelerated aging, the early onset of a variety of chronic diseases, cardiovascular diseases, cancers. And so you might also see this increasing inequity in life expectancy if what was happening was people are working so hard and under uncertainty and hard conditions that it wears away at their bodies.

Lofton: So you’re basically pointing to research that shows that chronic stress can impact the body’s health responses. So how healthy somebody is, is impacted by their stress in their lives.

Geronimus: Right and also how chronic it is, or unremitting, the different kinds of stress people think of stress is sort of just a feeling. But it’s more than a feeling. It’s a biological reaction and it can be triggered by feelings. But it can also be triggered by environmental factors, toxins in your environment, by sleeplessness, by working night shift jobs, from anxiety about how you’re going to make ends meet, how you’re going to get food on the table, how you’re going to pay the expensive hospital bill. You know, people have this vague notion of stress, but the stressors I’m talking about, include that idea of stress, but so much more.

Lofton: So I mean, but let’s tease this out a little bit. If you are chronically stressed about how you’re going to get to work, and how you are going to put food on the table for your family. I mean, doesn’t that contribute to a sense of despair?

Geronimus: It can, but the distinction that I’m making is despair, first of all, is entirely a feeling. And especially if you talk about deaths of despair, and look to suicide and opiate overdose, and put those together, it kind of paints this picture of people who just give up and tune out – just unproductive and depressed – and either literally kill themselves or kill themselves over time – or take risks that could have killed themselves very quickly.

That’s a very different thing than what I’m talking about, which is engaging with tenacity and even kind of hopefulness, the difficult obstacles – going to the two jobs, waiting for the bus, you know, not just going off and getting a drink. But that’s kind of what, in jargon is called “high-effort coping.” [It] itself can harm your body if it’s chronic. When the going gets as tough as it’s gotten for the least educated Americans over the last 25-30 years, if they choose to try to engage and support their families and themselves anyway, it’s sort of like batting their head against the wall.

Lofton: So you actually do talk about this quite a bit this idea of educational inequity and the role that educational inequity plays in sort of health disparities. Can you talk to me a little bit about that?

Geronimus: In our study, we looked at the least-educated Americans at any given time. So it’s not just [having] less than say, than [a] high school [education]. Because if [it] were, if you didn’t graduate high school 50 years ago, that might not be a big deal. But if you don’t graduate high school now, it certainly is, in terms of your opportunities. And over this period of time, because we’ve moved so much to a high-tech economy and an automated economy and a globalized economy, people with the least education are having the hardest time now finding jobs in our current economy. And even those who have them, and have had them even consistently, their real wages have stayed stagnant for 30 years, while prices of housing, food, health care, everything’s skyrocketed. So if your wages have stayed the same, your life is harder, even if you are employed.

Lofton: So what is the takeaway? What do you hope the study will contribute to the general conversation around the data that shows that Americans are not living as long as they used to?

Geronimus: That it shows that the main drivers of [death among low-income Americans] are cancers and cardiovascular diseases and internal causes. And that points in different directions than if you think people are despairing and taking drugs. And you would come up with different policies to address it. And as a researcher, we would pursue different avenues in researching it. And if in fact, it’s related to keeping on keeping on, even in the face of early onset of diseases and low wages and great uncertainty and illness in your family. That certainly points in directions that are different than ‘let’s just make sure we get opioids off the streets.’

This article was originally published by West Virginia Public Broadcasting.

Appalachia Health News is a project of West Virginia Public Broadcasting, with support from Marshall Health and Charleston Area Medical Center.

Rural Policy: ‘Here’s What We Need,’ Advocates Say

(Top photo: Shawn Poynter) Marlene Chavez, director of community engagement and outreach at Texas Rio Grande Legal Aid, speaks on a panel with Maureen Holland at the 2018 Rural Assembly in Durham, North Carolina. (Bottom, left to right) Carlton Turner, director of the Mississippi Center for Cultural Production; David Lipsetz executive director of the Housing Assistance Council; and Anna Claussen who leads rural climate dialogues that engage communities on initiatives to address climate change

The Trump administration and Democratic presidential candidates have had a chance to sound off on what they think needs to happen in rural America. Now we hear from advocates on the ground who identify the key policy changes they think would do the most good for rural America.

Rural America is ready to contribute more to the nation’s health and economic vitality, say advocates working in community development, education, healthcare, philanthropy and other fields.

To unleash that potential, rural America needs strategic support for the people, institutions and infrastructure that underly all successful communities, they say.

The Daily Yonder, working with the Rural Assembly, identified a dozen rural-policy advocates with firsthand knowledge about the impact of federal policy in rural communities. We asked these in-the-trenches experts to name the top policies they would like to see 2020 presidential candidates address and eventually enact. (The Rural Assembly is a national network of rural leaders. It is managed by the Center for Rural Strategies, which also publishes the Daily Yonder.)

New or increased funding for rural programs is on the agenda. But other themes include a call for inclusion, cultural parity, redirecting programs for more community impact and holding large institutions accountable for the way they serve rural America.

Arts and Culture

Carlton Turner

Carlton Turner is the Director and Lead Artist of the Mississippi Center for Cultural Production, which promotes local economic development through media and arts initiatives. Based in Utica, Mississippi, Turner oversees initiatives to mentor lower-income community members in agribusiness and media.

The rural arts landscape is beautiful and unique all on its own because it is made up of stories that reflect a culture of amazing people with rich and complicated histories. We will never have the infrastructure of urban art centers, neither should we seek to emulate them. But we do need our stories to be validated. We need our artists to know that their stories matter. We need spaces for our children to lean into the stories that connect them to their identity, to learn how to share their dreams and imaginations with pride, to use the tools that speak to them, whether they be on analog or digital platforms. Our communities also need exposure to the disciplines that have the potential to speak to them: dance, music, theater, film, etc. We also need meaningful exchange with artists who share perspectives and life experiences connected to, but different from, our own.

Our needs are simple. We need significant dedicated funding to support arts programming in the schools and beyond. We need a digital infrastructure (rural broadband) robust enough to grow connections with regional and global communities. And we need our arts spaces funded in ways that allow them to serve the communities’ basic needs to see their stories reflected in the myriad of ways that art shows up in our lives. We need rural arts support to be considered as an integral part of community health and wellness, not an afterthought.

Housing

David Lipsetz

David Lipsetz is the Executive Director of the Housing Assistance Council, which provides funding and expertise to local organizations developing affordable housing in rural communities.

From World War II to the present day, federal housing policy was designed to create suburbs and revitalize urban centers. Billions were spent on housing tax credits and deductions; millions of home purchases were publicly insured; trillions flowed through the secondary mortgage market’s government-sponsored enterprises. As a result, 52 percent of Americans now live in suburbs, and most of our wealth sits in a handful of metropolitan regions. It’s time to level the playing field and redesign federal housing policy to better include rural America in our plans for prosperity.

The 2020 presidential election is likely to put lots of attention on rural communities. It’s also likely to include a debate over housing policy. It’s about time! Rural housing is what we do at the Housing Assistance Council. It’s been our sole focus since 1971 and has allowed us to advise nine presidential administrations — a few of whom have even listened. This time around we’re reminding candidates: strong local institutions don’t happen by accident, and housing markets wither and die without access to capital. We suggest:

Invest heavily in the capacity of hometown non-profits to give rural communities a local champion and a fighting chance in the complex world of housing finance.

Channel capital to community development finance institutions to deploy in places banks can’t reach. It will prime those places for future private investment and allow the big primary and secondary mortgage market players to meet their duty to serve and reinvest in rural communities.

Our globalized, industrial food system is having devastating effects on people and the planet. From dead zones in the Gulf of Mexico to new strains of antibiotic-resistant diseases and the destruction of rain forests, the cost of our “cheap food” is going up.

U.S. farm policy is largely to blame, based on a persistent myth that our farmers must produce as much as possible in order to “feed the world.” This policy relic of the Cold War fueled the expansion of chemical-intensive, monoculture production on marginal lands, lowered crop and livestock prices, and drained the wealth from rural communities. It’s time to turn the page.

In its purest form, agriculture is an economic engine capable of generating rural wealth. It holds tremendous potential to restore soil health, protect our waters and mitigate climate change. Unlocking that potential requires new tools for farmers and a shift in policy to support more sustainable and regenerative farming practices.

For decades, bipartisan farm bills have included both farm safety-net programs (e.g. crop insurance) and food and nutrition programs (e.g. Supplemental Nutrition Assistance Program, SNAP). The strategy of combining rural and urban interests in the bills has served as a bulwark against the politics of division.

Going forward, we must make the health of people and the planet our guiding farm-bill principles. We must expand and strengthen rural-urban alliances to bring about the needed changes in policy. And we must put an end to the myth that we’re “feeding the world.”

Nationwide, there are 395 counties or parishes where the poverty rate has eclipsed 20 percent for three decades in a row. The vast majority of these are rural places. Those of us who live and work in persistent poverty areas know these challenges extend far beyond a chronic lack of income to the externalities of underinvestment. Low health and education outcomes fostered by dilapidating and aging community facilities, a lack of quality affordable housing and the proliferation of financial deserts all strike a common chord in regions such as Appalachia, the Mississippi Delta, the Black Belt, U.S. Mexico border, California’s Central Valley and in Indian Country.

As the 2020 election draws near, candidates should demonstrate a real commitment to expand investment in persistent poverty places by:

Supporting the 10-20-30 plan: The 10-20-30 plan requires federal agencies to designate 10 percent of all discretionary funds to be allocated to places where the poverty rate has exceeded 20 percent for the last 30 years. The plan should be comprehensive and include the U.S. Departments of Agriculture, Commerce, Health and Human Services, Housing and Urban Development, Labor, Transportation and Treasury.

Modernizing the Community Reinvestment Act (CRA) to increase lending and investment in rural areas: Too many rural communities exist beyond the reach of the Community Reinvestment Act. This phenomenon occurs because CRA links its requirements for lending, service and investment to places where bank branches exist. As a result, while large banks extract substantial profits from rural communities, they are not required to reinvest there because their physical presence is limited. CRA should require investment in these economically distressed places, including investing in CDFIs that serve these communities.

Philanthropy

Brian Fogle

Brian Fogle is the President of the Community Foundation of the Ozarks, a network of foundations and donors serving communities in central and southern Missouri. Based in Springfield, Missouri, Fogle consults with civic organizations and 49 affiliate foundations with $283 million in assets.

We’ve been talking about this for a long time. I remember over 20 years ago, when I was involved in the Stand Up For Rural America campaign, we had an ongoing dialogue with the Council on Foundations about rural funding. A few years later, there was a gathering in Montana to answer a challenge from Senator Max Baucus (who served represented Montana I the U.S. Senate from 1978 to 2014) to bring more philanthropy to rural America. The resulting product was a book and a continued decline in funding. If I’ve heard it once, I’ve heard it 50 times from funders “we can’t scale our programs in rural areas efficiently and effectively.” And that’s true—if we try to replicate large programs for small communities. It doesn’t work. As a result, funding continues to dwindle.

What many funders don’t realize is the impact that seemingly small dollars can have in rural places. As a community foundation serving many rural communities, we’ve seen recipients cry from a podium receiving a $5,000 check, knowing what that means for their hometown. For the price of a consultant in an urban area, you can have a tremendous, lasting impact in a small community. Rural citizens know how to make a little go a long way through volunteerism, grit and frugality.

Most of America is served by one of the 860 community foundations that exist in our country. They are all place-based and are governed by the people who know the area best—their residents. I think one of the best possibilities to serve rural America is for governments and national funders to work with their respective community foundation to address challenges and build community. They know how to scale giving to make it work, and they know the strengths and challenges of their community the best because they live, work and play there.

There is much hope and promise for rural America, still, but we need to halt the dialogue after several decades and start investing.

We must ensure our climate and environmental solutions are also rural community solutions.

Most of our natural resources essential for survival and critical in addressing our climate crisis are stewarded by rural people living and working across 84 percent of our nation’s geography. Rural people have lower life expectancy and higher poverty rates, are on average more food and energy insecure, and earn less than their urban counterparts.

The future of our planet – of our climate and our environment – is explicitly linked to the health and well-being of our rural people and places. It depends on policies and programs that prioritize rural equity, seeking to achieve a balance between economic and social vitality and commitments to long-term climate resilience. These policies must reduce—not increase—our historic discrimination and ongoing inequities (economic, racial, cultural, geographic, etc.) of vulnerability.

Examples of solutions that will achieve these aims:

Invest in efficient buildings and increase access to affordable and renewable energy sources, while prioritizing local ownership, for our rural communities to benefit from decreased energy poverty.

Support a diverse suite of locally determined conservation efforts across both public and private lands, including working landscapes, that support both vibrant rural communities and healthy landscapes.

Provide incentives for clean-energy infrastructure and community-based energy projects while simultaneously supporting our nation’s farms, towns and rural tribal communities in the transformation of their function and identity.

Ultimately, the most robust approach to addressing climate change and protecting our environment will come from a foundation of reciprocal exchange, intentional representation and authentic compassion. It will require slowing down to get there faster.

Jobs

Michelle Decker

Michelle Decker is the CEO of The Community Foundation, serving Riverside and San Bernadino, California. Ms. Decker has 27 years of experience in community economic development and previously served as the CEO of Rural Action, in the Appalachian region of Ohio, where she led efforts in social enterprise development.

The first thing each presidential candidate should do is declare that they have no clue about how to create more jobs in rural America. At that point, they should stop and wait for the influx of ideas from rural America. The main idea folks will share will be around infrastructure investment because unless that’s fair and equitable, rural America will have a hard time even floating a good idea.

Once that budgetary item is resolved, which I’m sure it will be (a huge investment in USDA Rural Development will work nicely), then we can discuss how rural America is rich with the sustainable, biological resources that our country requires for an energy, food and fiber independent future. We will talk about investing in the management of those resources, as well as the technological breakthroughs that will be required to use them sustainably.

The management will require some public funds (for U.S. Forest Service, BLM, etc.) but we think we can use private and public investment for the tech transfer ideas. But we’ll only use those dollars if the venture capitalists promise the jobs stay with rural America, and don’t have to move to San Francisco or other such places.

We will also promote a very large investment in the entrepreneurial culture of our rural communities through various vehicles, to foster our natural talent for figuring stuff out on our own and supporting local businesses to grow. This will involve our universities and community colleges and their incubators and accelerators, but there will be a clear-as-a-bell understanding that we have to build a resilient ecosystem to support job creators of all sizes, and that there is no silver bullet here.

There will also be a clear understanding that rural America is a prize, not a drain. Any investment pays back well. Our presidential candidates will listen deeply and make a clear commitment that every square inch of these United States of America is invaluable to the nation’s future and that of Planet Earth.

Education

Francisco Guajardo

Francisco Guajardo is Professor of Organization and School Leadership at the University of Texas, Rio Grande Valley. He is a national leader in place-based educational initiatives.

National strategy: Rural schools can learn from each, advocate for each other and share collective resources. Professional development for rural schools and communities often calls for theories and practices different from predominant educational thinking born out of urban educational settings. A national rural education strategy can address issues of professional development for teachers, school leaders and community advocates.

From deficits to assets: Rural schools and communities have wide-ranging strengths and assets, but popular perceptions continue to view rural schools and communities as poor, marginal and part of a hinterland reality. While conditions of systemic poverty may grip many rural schools and communities across the country, those same schools and communities also have strengths, virtues and proud histories. To move from deficits to strengths can impact the psychology of a school and a community; it can produce a shift from hopelessness to hope and opportunity. To build rural school and community strength often requires a change in consciousness, before rural folk feel good about working for positive change.

Tackle rural poverty: Rural schools and communities continue to be mired by conditions of poverty and low levels of educational investment, a historical pattern that has grown unabated. Poor health care, inferior access to technology and local economies without strong employment opportunities perpetuate conditions of rural poverty. Local, state and federal policies can impact conditions of poverty, but policymakers must understand rural poverty before they create policy opportunities for rural schools and communities.

Technology, tolerance, talent: Rural schools have a history of incubating innovation, invention and creativity. Places that do that generally offer access to technology. They are places that are culturally and socially tolerant, and they figure out ways to hold onto their talented people–and in some cases recruit talent. In the Rise of the Creative Class, Richard Florida argues that the most creative communities, including rural places, emerge as creative communities because they focus on technologies, on being tolerant and on nurturing local talent. I grew up in a rural school that met that criteria.

Health

Alan Morgan

Alan Morgan is the President of the National Rural Health Association, a network of individuals and organizations engaging in research and advocacy for rural health policies.

As mortality gaps between rural and urban Americans escalate, three in five rural voters say they would be more likely to vote for a candidate in the 2020 election who prioritized access to health care in rural America.

Access to care for many rural patients has worsened. One hundred eight rural hospitals have closed since 2010, more than 46 percent of rural hospitals are currently operating at a loss, meaning hundreds more will close if federal policies don’t soon change. When rural hospitals close, they rarely reopen — rural patients are left without emergency room access, and 20 percent of a community’s economy vanishes. Health disparities and economic decline ensue. Most closures are occurring in areas where hospitals are needed most — in communities of high health disparities, high poverty and high minority populations.

Drastic and draconian Medicare cuts and the lack of Medicaid expansion are closing rural hospitals. The Save Rural Hospital Act will both stabilize current reimbursements and create the Community Outpatient Hospital, a new model that offers the flexibility needed for rural communities. Rural hospitals must be empowered to deploy innovative approaches to deliver care that protects emergency access.

Healthcare workforce shortages plague rural America. (About 20 percent of the population is rural, yet only 9 percent of physicians work there.) Hundreds of rural maternity wards have closed, leaving 54 percent of rural counties without hospital-based obstetrics and creating high risks for mother and child. Overcoming chronic shortages is vital; support of workforce development programs and telemedicine is critical.

Citizenship

Marlene Chavez

Marlene Chavez is the Director of Community Engagement and Outreach at Texas Rio Grande Legal Aid, which provides free legal services to 23,000 low-income farmworkers, veterans and disaster survivors. Edyael Casaperalta is a Fellow at the American Indian Law Program of the University of Colorado Law School, where she researches and writes about federal Indian law, indigenous peoples’ rights, international human rights and telecommunications and technology.

The strategies of terror embraced by the current administration hurt rural communities. Terror tactics such as separating children from their parents, locking up children in make-shift camps, conducting highly-publicized Immigration and Customs Enforcement (ICE) raids, adding a citizenship question to the Census, withholding the rights of Americans of Muslim faith and deploying a task-force to reopen cases of citizenship, among others, hurt rural Americans, our neighbors, our families and threaten our communities. We want the next president to renounce and halt these tactics designed to reverberate fear throughout our communities. We want the next president to address the following areas of migration policy:

Fund rural America’s progress, not waste public funds on a border wall.

Edyael Casaperalta

Since 2007, the U.S. government has spent billions of dollars in the construction of barriers across the border with Mexico. In May of 2018, the U.S. Army Corps of Engineers released a study indicating where new segments of the border fence are to be constructed in the Rio Grande Valley, overriding environmental concerns, impact on water level, increased risk of flooding, and possible violations of a treaty with Mexico. The billions of dollars in taxpayer money spent to pursue and build this wall are better spent in addressing socio-economic problems in rural America. These funds should go to helping the 17 million of rural Americans who live in areas without a rural health clinic, end the hunger that plagues 2.4 million of rural households, reopening the 102 hospitals that were closed in rural communities, and close the digital divide for the 23.4 million of rural Americans still lacking internet access.

Protect the right to asylum

The Trump Administration has implemented the Migrant Protection Protocol in some areas of California and Texas and on July 16, 2019, announced plans to expand it. This program requires certain asylum seekers to begin their asylum cases in Mexico or Guatemala, yet both countries have not agreed to acting as a “3rd country.” This protocol poses an extreme burden on their right to apply for asylum. Many migrants have no living arrangements in Mexico or Guatemala and are forced to rely on shelters or other unstable living arrangements while they are there. Border cities are often dangerous, and asylum seekers may be subject to additional persecution and danger while they await a decision in their cases. This protocol also gives border patrol agents unfettered discretion to decide that someone is not an asylum seeker and should return to Mexico, even involuntarily, without any review by an immigration judge. This is a potential violation of the Convention Against Torture and the Foreign Affairs Reform and Restructuring Act which says that it is U.S. policy “not to expel, extradite, or otherwise effect the involuntary return of any person to a country in which there are substantial grounds for believing the person would be in danger of being subjected to torture.” 8 USC 1231.

Uphold our tradition of citizenship

It is an American tradition, affirmed by the 14th Amendment to the Constitution and the Supreme Court, that those born in the United States are automatically U.S. citizens. Since the late 1800s, our nation chose to bestow citizenship automatically upon those who are born within our territory. In January, a bill that would limit the American tradition of citizenship to apply only to those born to a parent that is a citizen, legal permanent resident or served in the U.S. military. This effort is yet another attempt to control the migrants that join our communities. But rural America has always been a land of migrants. Since the inception of our nation, rural communities were the destination for millions of New Americans. It is in rural towns, farms and local governments that newcomers forged their identity as Americans and did the work to build each state of our nation. This bill will not stop migration from taking place, migrants from giving birth to new Americans, nor migrants from becoming the linking threads in the fabric of rural America. This bill will only serve to limit the pool of talent that joins and takes root in rural communities. This bill goes against the rural tradition.

Technology and Broadband

Roberto Gallardo

Roberto Gallardo is Assistant Director of the Purdue Center for Regional Development at Purdue University. He has written numerous articles for the Daily Yonder and is a Senior Fellow at the Center for Rural Strategies, which publishes the Daily Yonder.

Talent exists everywhere; the ecosystem under which it thrives does not. As the digital age continues to unfold, rural communities are at risk of being left behind. The following areas need to be addressed to ensure rural communities can participate fully in the digital age:

Ensure mechanisms where adequate and affordable broadband is a reality in rural areas. This may include better aligning existing resources and incentives to smaller providers that are vested in these rural communities and/or explore open access models in areas where dedicated infrastructure is too expensive to build.

Provide resources and technical assistance to rural communities to improve their ability and capacity to pursue funding mechanisms to upgrade their broadband infrastructure.

Design, fund and implement a national strategy delegated to states that addresses digital inclusion, including devices, adequate and affordable connectivity and digital skills/literacy.

Increase awareness efforts throughout rural communities on the implications of the digital age and how they can plan for, transition to and prosper in the digital age.

Assist rural communities in shifting their economic development strategies from industry attraction to placemaking and economic gardening, strategies that focus inward rather than outward.

This articlewas edited and compiled with the assistance of Charlie Zong. It was originally published by the Daily Yonder

Q&A: Why We Need Better Reporting on Rural America

Journalists Sarah Smarsh and Ken Ward Jr. discuss the state of rural journalism at Robert Wood Johnson's Life in Rural America symposium. Photo: Shawn Poynter, courtesy of the Robert Wood Johnson Foundation.

Is there room to tell more complete stories about the diverse circumstances and perspectives in rural America? We better hope so, says Kansas native Sarah Smarsh, author of the bestselling memoir “Heartland: A Memoir of Working Hard and Being Broke in the Richest Country on Earth.” Smarsh speaks with veteran coal reporter Ken Ward Jr. about the relationship between good journalism, community health and our collective future.

Journalists Sarah Smarsh and Ken Ward Jr. have made careers out of telling complicated but compelling stories.

Smarsh is up for a National Book Award for her memoir “Heartland,” which examines her rural Kansas upbringing. Ward just received a MacArthur fellowship (a.k.a. the MacArthur “genius” award) for his long career covering the coal industry from its Appalachian epicenter in West Virginia.

Ward interviewed Smarsh in May in Charleston, West Virginia, at a national rural-life summit sponsored by the Robert Wood Johnson Foundation, a national funder of health-related projects. (Disclosure: The Center for Rural Strategies, which publishes the Daily Yonder, receives funding from the foundation.)

The reporters talked about American journalism’s portrayal of rural people and the need for Americans to build a more accurate and complicated understanding of rural communities and issues.

The following question-and-answer format article is based on that interview. It has been edited for length and clarity.

Ken Ward Jr.: You’ve been doing a lot of traveling around and talking to people in rural America. I sense that there’s a different conversation going on there [than we hear about]. What are people in rural America talking to each other about and talking with you about that maybe the chattering class needs to listen to?

Sarah Smarsh: The story that’s told about [rural places] is largely a false narrative, and there’s great dissonance between the prevailing stereotypes and tropes about rural America and what’s actually happening on the ground. If you’re a cable news network, and you like conflict, and you want to whip up the idea of cities versus country (which drives up ratings and enforces some sort of unfortunate cultural identities), then you put up a map of the United States where each state is colored either red or blue, as though that monochromatic color would represent everyone in that state.

Actually, in 2016, in just about every state, almost 40 percent, so almost two out of five people, voted for the candidate who lost in that state. So we’re sort of rendering invisible millions of people when we use terms like “Trump country” and reduce regions to political monoliths.

So ultimately, those maps I think are very misleading. When I’m talking to people on the ground, it is a much more promising picture than you would think from CNN or MSNBC. People are coming together as communities across even political boundaries and working in a space that I would call localism, like how do we solve these problems locally when we’re feeling not only misunderstood but perhaps even scorned and scapegoated on a national level?

Ward: I’m wondering is it really even appropriate to talk about one rural America, and to assume that farmland in Kansas and the people who live there have all the same ways of doing things, and thinking, and talking as people in the coalfields of southern West Virginia, or steel country in western Pennsylvania and Ohio? Is there room in this space for what could be lots of different rural Americas?

Smarsh: There had better be room if we want to understand ourselves accurately as a country. Unfortunately, the way the power structure works is whoever gets to set the narrative often has a blind spot to the spaces with less power. Sometimes, it’s with direct malice, but sometimes it’s just for a sort of ironic ignorance at the top that the story is told in a way that is reductive to a dangerous extent.

Of course, there’s not just one rural America. I happen to be a white, fifth-generation wheat farmer. I grew up on a flat expanse in the middle of a country. I happen to have been born into a sort of stereotype, in terms of imagery. My dad has been a construction worker for decades. He wears a hard hat, and he’s got a farmer’s tan, and he struggles to get dental care. We carry with us the symbols of rural America, and yet what those symbols would represent to someone about who we are, let’s say politically, would be actually the opposite of the way that my particular family votes and believes in things. My dad’s favorite politician, by the way, is [U.S. Representative] Maxine Waters [D-California 43rd].

Ward: What are the health concerns that you think rural Americans have, based on what you’ve heard in the places you’ve been or the place that you’re from?

Smarsh: I was just talking in Hutchinson, Kansas [population 42,000]. It’s only 30 miles from the farm that I grew up in [in central Kansas] They have a local health initiative called Heal Reno County. It was a beautiful evening, standing room only. One hundred people showed up to talk about this not very sexy topic of health.

Every single person in there, during the hour-long Q-and-A engagement, was saying, “Why isn’t our state expanding Medicaid?” This is so counter [to national media representations of rural]. A TV studio in New York would be stunned that that’s the line on the ground. Then I can just hear right now comments on some national news, at the bottom of the story, “Well, then why did they vote against it?” Or, “Why did they vote against their best interest?” That presumes, again, that this places a political monolith. What I try to tell people, when they want to cast an entire state or region in one particular way politically or culturally, “If you right now do not feel represented by our federal administration, then perhaps logically you can imagine that within the smaller political unit of a state, or even a county, or city, you could live there and not be represented by the people who are in office.”

Ward: How do you have a dialogue with someone who starts off with, “That’s what you get for voting that way”?

Smarsh: The first way that I come at any conversation about community progress is humility about not presuming that I know better than the person walking in his or her shoes. I come by that humility easily in the political sector because I was raised with somewhat different political views than I and my whole family hold now. I wasn’t a worse person then, and I’m not a better person now. I’m the same person with extremely different sets of information.

Ward: Where can we find information to better understand what’s happening in rural America?

Smarsh: I think that part of how we rectify this concern of different sets of information is local news, but it’s also the national news paradigm that increasingly… It’s like this perfect storm, where so much local reporting has fallen and not yet been built, even though there are great efforts going on to that in the digital era. The big dogs that were left are where people increasingly turn for all of their stories and narratives, and that is the national networks. If you’re sitting in your recliner in small-town Idaho, and somebody in New York is telling you a story about your place as though it’s the truth, this is sort of a disconnect. We have half the country watching Fox News and half the country watching MSNBC. While I’m all for increasing efforts on the local level, there is something that is so toxic in that top-level system being broken from the rest of the information sphere that that’s, I think, a bigger problem to contend with.

Ward: How does class figure into your work?

Smarsh: Actually, the first thing that I wrote that quote-unquote, went viral … was an essay called “Poor Teeth” about lack of access to dental care. It centered on my dad’s struggle. Well, my dad had a cavity turn into an infected root, and then ultimately it turned into sepsis, and almost killed him. In 2014, a lifelong construction worker has a nearly fatal bout with a rotten tooth, basically. That’s in the richest country on Earth.

So many people contacted me. Thousands of people sent me messages about that story that said that somehow that had never quite been articulated. I was thinking, “What in the world? How we are at this moment in our supposedly advanced society when people just haven’t even felt…” There is such a veil over the truth about economic inequality in this country, and the ways in which it intersects with race, gender and a whole bunch of other aspects of identity, that in 2014, all I did was articulate it, and then people were like, “I’ve never heard someone say this.”

The trick that we do socially and culturally to ensure that veil stays up has to do with shame. My dad felt ashamed to talk about his teeth and very bravely let me do so with his blessing, but when you’ve got to keep up these appearances, like, “This is bootstrap America and I’m getting by on my own,” that doesn’t leave much space for the vulnerability of, “And meanwhile there’s poison in my blood because I can’t afford a dentist.”

Ward: One thing that I struggle with is, to what extent some of these must-pull-myself-up-by-bootstraps sort of narratives are internalized and coming from us, and to what extent they are being overly reinforced by some national media portrayal?

Smarsh: I think that it is both coming from popular culture and news media, but it also arises from within the very community. That’s why I go back to why narratives matter and words matter because the hell of it is, you can start believing the lie about yourself. The way that this keeps us from progressing as a country is, again, we are dealing with things without looking right at some of the most glaring problems.

Ward: How is the way we tell stories important for matters of health?

Smarsh: I think when we talk about health, it’s easy to think of this as a wholly physical concern, but health and wellness, of course, as you all know, goes beyond that. There is something that I would call just a… I hesitate to use the word spiritual because I don’t necessarily mean that in any context that remotely involves God or religion. But if you just think of your being, your sense of your relationship to the world, the universe. If every story being told about you is that you’re backwards, ignorant, your community is dying, why don’t you just leave, and meanwhile, you’re doing the work of picking the lettuce in California or raising the wheat in Kansas that’s on the plate of the people who are carelessly levying those condescending comments, that is a bitter pill to swallow spiritually and psychologically.

I don’t know how to back this up other than my own lived experience. That has reverberations in the way of wellness and health, whether it’s that shame or a sense of not being validated somehow. It’s related to a general malaise and a need to self-medicate. The stories that we tell about ourselves and about specific populations within our country, they affect the wellness of those communities.

‘Cities v. Country’: Focus on Divide Means Rural Voices Go Unheard

Sarah Smarsh, left, was the keynote speaker at the Robert Wood Johnson Foundation's Life in Rural symposium in Charleston, West Virginia. Photo: Shawn Poynter/Courtesy of the Robert Wood Johnson Foundation

Granted, Nick Smarsh isn’t likely among the majority of rural Americans in his unabashed admiration for Waters. But he’s certainly not alone.

Debunking stereotypes of rural America – as monolithic, as “Trump Country” – was a primary topic of conversation at the Life in Rural America Symposium held last month in Charleston, West Virginia, in conjunction with the release of the “Life in Rural America: Part II” report by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health from surveys of 1,405 adults living in the rural U.S.

The message emanating from Charleston was clear: Rural America is politically, racially and economically diverse. It’s the mountains of Appalachia, Midwest farmland, the Mississippi Delta, the Great Plains, Hispanic and Native-American communities scattered throughout the country, Mormon communities in the west. Out of that diversity come a myriad of narratives.

Sarah Smarsh, left, was the keynote speaker at the Robert Wood Johnson Foundation’s Life in Rural symposium in Charleston, West Virginia. Photo: Shawn Poynter/Courtesy of the Robert Wood Johnson Foundation

As keynote speaker at the symposium, Smarsh, author of the bestselling Heartland: A Memoir of Working Hard and Being Broke in the Richest Country on Earth, shared her father’s affinity for Rep. Waters. And she joined a chorus of speakers and other attendees in emphasizing the importance of hearing the many voices of rural America.

“A problem well-stated is half-solved,” Smarsh said of the issues rural Americans face today, quoting inventor Charles Kettering. But it must be articulated from within.

Narratives, if genuine, matter, she said. “Because the hell of it is, you can start believing in the lie about yourself.”

Debunking the Mainstream View

Certainly, symposium panelists acknowledged, there are issues common to the whole of rural America. Among the “Life in Rural America” report’s findings are that 64 percent of rural residents believe that better long-term job creation would be most helpful to their local economy, 61 percent believe that improving the quality of local schools would be most beneficial and 55 percent point to improved access to health care.

The report also suggests that the solutions lie within rural communities. While a majority of those interviewed in the survey acknowledged that assistance from the federal and state governments is required, more than half said they’re active in solving problems in their community – with younger adults reporting higher levels of participation – and two-thirds said their neighbors have helped them in times of need.

Ed Sivak, executive vice president of policy and communications for the Hope Enterprise Corporation, presented data that could help move rural communities toward equity. Photo: Shawn Poynter/Courtesy of the Robert Wood Johnson Foundation

“The way I look at it,” said Ed Sivak of the Mississippi-based Hope Enterprise Corporation, a nonprofit community development financial institution, “there ain’t nothing wrong in rural America that can’t be fixed by what’s going right.”

Smarsh spoke of the “promising picture” of rural America that she encounters in her travels – of people coming together as communities across political boundaries and “working in a space of what I would call localism, of, ‘How do we solve these problems locally, when we’re feeling sort of not only misunderstood but perhaps even scorned and scapegoated on a national level?’”

The story that’s told in the media about rural America, she asserted, is largely a false narrative. “There’s a great dissonance between the prevailing stereotypes and tropes about rural America and what’s actually happening on the ground,” she said.

“If you’re a cable news network, and you like conflict, and you want to whip up the idea of cities versus country – which drives up ratings and enforces some sort of unfortunate tribal identities – then you put up a map of the United States where each state is colored either red or blue, as though that monochromatic color would represent everyone in that state.”

In fact, Smarsh pointed out, in the 2016 election around 40 percent of voters in a majority of states selected the candidate who lost that state in the presidential election. “So we’re sort of rendering invisible millions of people when we use terms like ‘Trump Country’ and reduce regions to political monoliths.”

Local Talent

Rural communities are staking claim to their future.

Ines Polonius, CEO of Communities Unlimited, Inc, a not-for-profit that provides economic-development assistance in southeastern states, said that community development should begin with a focus on assets, not deficits. This approach “begins to shift mindsets, and it begins to create hope.”

Polonius spoke of structuring “entrepreneurial ecosystems” that allow communities “to build their economies from the inside.”

“A lot of times what we find is that as we identify leaders that have really creative ideas and we bring them to the table, they’ve never been in a position where they’ve had the opportunity to lead,” Polonius said. “They’ve never had an opportunity to be in a room with other leaders and actually work together and work through implementation.”

Lisa Mensah, president and CEO of Opportunity Finance Network, a national association of community development financial institutions, or CDFIs, joined Polonius in a panel discussion of capacity building and advancing economic opportunity.

In a recent op-ed piece for The Daily Yonder, Mensah reported that 85 percent of the nation’s 353 persistently poor counties are rural. CDFIs, Mensah wrote, play a critical role in lifting rural economies. They have “proven experience and the conviction that decent housing, clean drinking water and life enriching community facilities and opportunities can happen in even the remotest and poorest areas.”

“We know how to solve problems in rural infrastructure, housing, banking, small business and healthcare,” Mensah wrote, and underscored in Charleston. “The solution is capital, resources and perseverance.”

Jen Giovannitii, left, president of the Claude Worthington Benedum Foundation, joined a panel at the Life in Rural symposium to discuss how rural communities can move toward solutions. Photo: Shawn Poynter/Courtesy of the Robert Wood Johnson Foundation

Jen Giovannitti, president of the Claude Worthington Benedum Foundation, which provides grant assistance throughout southwestern Pennsylvania and West Virginia, spoke of the importance of making disruptive investments in rural communities – by investing, for example, in CDFIs.

“Banks are not providing all of the services that we need for small businesses, housing and health care,” Giovannitti said in a post-symposium interview. CDFIs are making that investment.

She cited as an example investing in young family-practice physicians, dentists and pharmacists who want to settle in a rural community. They’ve accumulated enormous debt from their education and the cost of starting out on one’s own can be prohibitive. Banks consider them a poor risk.

Investing in those practices, Giovannitti said, is an investment in both the health and economy of that community.

“So this, for us, disrupts the system,” she said. These young health care professionals “might not be able to make that happen in a traditional setting. But these intermediaries,” the CDFIs, “can make it happen.”

A Seat at the Table

The well-stated consensus in Charleston was that the foundation for development in rural communities is capacity building and leadership training. But there then must be a seat at the larger table.

“One of the reasons why rural America doesn’t get the resources it needs is because it is not really at any of the tables where those decisions about rural America are made,” Brian Dabson, a research fellow at the University of North Carolina School of Government, said.

“We go through the motions of putting our arms around and saying we care for each other,” Dabson offered, “but that’s not the reality in the way the large-scale resources are allocated. It’s who’s got the power. And until we redistribute that power, then we’ve got to put a Band Aid over it and deal with it at the local level and take care of ourselves within that unfair context.”

Demanding “equal voice, equal power,” he said, is of the essence.

“We don’t want to be in denial,” Dee Davis, founder and president of the Whitesburg, Kentucky-based Center for Rural Strategies, said, “but we also know that you really can’t build a way forward unless you’re working with an understanding of your assets and lifting them up.”

He’d made a list of assets discussed throughout the day that he felt are “worth hanging onto.” Among them: diversity, family, heritage, humor, entrepreneurial spirit, common purpose, striving for a better world for one another’s children … that “the mountains are our grandfathers” (“I want to be a mountain for someone,” Davis avowed.) … “that we aren’t supplicants, that we have standing to negotiate” … “our connections in systems and connection in story.”

Davis was encouraged by what he’d heard and experienced this day.

“People are very certain of who’s going to make it and who’s not,” he said. “But we should be a little careful in making these projections, because there are a lot of balls in the air, and we’re not sure how they’re going to fall.”

Editor’s Note: The Center for Rural Strategies produces The Daily Yonder, a publishing partner of 100 Days in Appalachia.